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Cracked skin of feet: an ignored entity in the tropics

  • National Intensive Care Surveillance
Vol. 49, No. 3, September 2004 101
Research letters
Pubudu de Silva, Medical Officer, Sampath Kusumsiri, Medical Officer and Rani Wasala, Paediatrician, Sri
Jayewardenepura General Hospital, Nugegoda, Sri Lanka.
Correspondence: RW, Tel: +94 11 2778610, e-mail: <> (Competing interests: none declared). Received
25 March 2004 and revised version accepted 20 April 2004.
Vertical cracking of skin at the edge of the soles is seen
in many adults of Sri Lanka. However, none of the standard
textbooks on dermatology or general medicine describe it
as an entity. We were able to find it mentioned in one text-
book written by Finnish and African authors [1]. A survey
of MEDLINE using key words “cracking of skin”, “cracked
skin” and “splitting of skin” did not reveal a single article
suggestive of this disorder (accessed on 14 October 2003).
The objective of our study was to assess the preva-
lence, complications and possible aetiological factors of
cracked skin of feet.
We conducted two pilot studies in adults (>18 years)
from rural areas (Moneragala District) and in an urban
population (National Hospital, of Sri Lanka). In the rural
study, the samples consisted of consecutive adults attend-
ing the general Outpatients’ Department (OPD) of
Moneragala Base Hospital (n=42) and those selected from
a community survey (n=33). In the urban study the preva-
lence was noted from a consecutive sample of adults at-
tending the general OPD of the National Hospital of Sri
Lanka (NHSL) and living in Colombo (n=100). Exclu-
sion criteria were the presence of serious illness, requir-
ing bed rest or overt skin disease (such as allergy).
A separate case control study of 112 persons was also
conducted in the general OPD of NHC, with those observed
to have cracked skin of feet being matched for age and
sex. Trained pre-intern medical officers collected data and
examined participants using structured questionnaires.
The results of the rural study revealed that there were
46 with cracked skin of feet (overall rate of 61.3%, mean
age 38.1 years, male:female ratio = 12:34 = 2.83) and 29
(38.7%) without (mean age 20.4 years, male:female ra-
tio = 11:18 = 1.63). The principal complaints were that
of pain (23, 50%) and bleeding (7, 15.2%). Pruritus was
rare (present only in 2). Moderately or very thick skin in
the soles were observed in 43 (93.4%) of those with
cracks, whereas only 12 (41.4%) controls had the feature
(p<0.05). Regular footwear was used by six (13%) of
those with cracks and 11 (37.9%) controls (not significant).
To the Editor:
Cracked skin of feet: an ignored entity in the tropics
In the urban study, 58 (58%) of the subjects (mean
age 42.7 years, male:female ratio = 34:24=1.42) had
cracked feet during the past year, while 66 (66%; male:
female ratio = 37: 29=1.27) claimed to have had the prob-
lem at some time during their life.
The case controlled study did not show a statisti-
cally significant difference in the two groups for use of
footwear, positive family history, dry skin (subjective
assessment) and body weight. Thick skin was noted
in 69 (61.6%) of cases and 15 (13.4%) of controls
(p<0.05). Complications included pain (n=56, 45.9%),
bleeding (n=23, 18.9%), pruritus (n=10, 8.2%) and in-
fection (n=6, 4.9%).
This is the first report on cracked feet in the litera-
ture to our knowledge. The results indicate a high burden
of problems such as pain and bleeding in this disorder.
Its possible role in serious complications such as diabetic
foot disease needs further investigation.
Thick skin was found to be the only significant factor
associated with skin cracking in both rural and urban areas.
The single reference suggests that walking barefoot results
in thickening of skin, which gets cracked from trauma and
drying, but quoted no reference [1]. Investigations are being
done to identify other likely mechanisms of the disorder.
We thank Drs Vinod Elangasinghe, Indika
Meegahawatta, PL Atapaththu (DMO, Badalkumbura)
and health staff from Moneragala District for their assis-
tance, and the Development Studies Institute of the Uni-
versity of Colombo for funding.
1. Paananen H. Common Skin Diseases. In: Lankinen L,
Bergstrol S, Makela PH, Peltomaa M, eds. Health and
Disease in Developing Countries. London: The Macmillan
Press Ltd., 1994:271-280.
9. Prasad B, Costello AM de L. Impact and sustainability of
a “baby friendly” health education intervention at a dis-
trict hospital in Bihar, India. British Medical Journal 1995;
310: 621–3.
Saroj Jayasinghe, Associate Professor, Pubudu de Silva, S Mathankumar, KLADT Ranasinghe, MDA Rodrigo and
AADCJ Weerathunga, Research Assistants, Department of Clinical Medicine, Faculty of Medicine, Kynsey Road, Colombo 8.
Correspondence: SJ, e-mail: <> (Competing interests: none declared). Received 20 October
2003 and accepted 17 January 2004.
10. Hakim I, El-Ashmawy I. Breast-feeding patterns in a ru-
ral village in Giza, Egypt. American Journal of Public
Health 1992; 82: 731–2.
Full-text available
In a longitudinal study of infant feeding in rural Giza, Egypt, we found that 68.8% of the recruited mothers initiated early suckling of colostrum, but only 51.2% of the infants were exclusively breast-fed in the first week. Solid foods were introduced much earlier than at the recommended age of 4 to 6 months. Sixty percent of the mothers who participated in the study considered breast-feeding plus regular or irregular complementary feeding to be exclusive breast-feeding.
Full-text available
To evaluate the impact and sustainability of a baby friendly training intervention for staff at an Indian district hospital on initiation of breast feeding and use of prelacteal feeds by mothers. Intervention study with assessment by interviewing mothers. 172 mothers recruited before the intervention, 195 recruited immediately after the intervention, and 101 recruited six months later. District hospital in a small town in Bihar, India. Age of infant when breast feeding started, use of prelacteal feeds, and colostrum feeding. 10 day training programme for doctors, nurses, and midwives, explaining the benefits and feasibility of early breast feeding and dangers of prelacteal feeds together with instruction on explaining this information to mothers. Breast feeding was started within 24 hours of birth by 53 (29%) of control mothers, 164 (84%) in the early follow up group, and 60 (59%) in the late follow up group. Prelacteal feeds were used by 165 (96%), 84 (43%), and 78 (77%) respectively. Only 36 mothers in the late follow up group reported receiving education on feeding. Mothers in this group who had received the education were significantly more likely than mothers who received no education to breast feed early (28 (78%) v 11 (17%), P < 0.001) and not use prelacteal feeds (21 (58%) v 2 (3%), P < 0.001). Training doctors and midwives greatly improves the feeding practices of mothers. However, the impact of the training fell off quickly and refresher training is needed to sustain the improvement.